I. Reproductive Medicine & Infertility Associates (RMIA)...patient is committed to keeping those...

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© 2016 G:Electronic Documents/181 All Rights Reserved 9/15/16 Page 1 of 4 Reproductive Medicine & Infertility Associates In compliance with the Federal Consumer Credit Protection Act, we wish to notify you of our policies regarding the payment of statements for services rendered on your behalf. Please review the following information regarding our two separate corporations, as there are distinct differences between them in the way payment is collected for services rendered. We want to be certain that you are well informed, so that you are able to have your questions answered prior to having any services performed. I. Reproductive Medicine & Infertility Associates (RMIA) RMIA/General Reproductive Health Center participates with most major insurance carriers and will provide services including (but not limited to): Physician visits/consults Second opinions Ultrasounds Infertility testing (excluding male diagnostic tests, see below) Ovulation induction Inseminations (excluding sperm preparation, see below) Confirmation of pregnancy General surgery done off-site RMIA will verify in advance that coverage exist for services regarding consults, general infertility testing, and treatment. If services are covered, then RMIA will bill the insurance carrier directly. Once the insurance carrier has addressed the claim, RMIA will bill the patient for any remaining financial responsibility. If upon verification of insurance benefits it is known that your insurance does not cover certain services rendered by RMIA, then it is our policy to secure a credit card from the patient to cover the services rendered. If a patient hasn’t met his/her financial obligation after a treatment cycle, no further treatment will be conducted until the account has been settled. II. Infertility Laboratory & Surgery Center Associates (ILSCA) (Prices subject to change) ILSCA does not participate with any insurance carriers and will provide services including (but not limited to): In vitro fertilization (IVF) Andrology – male diagnostic testing and intrauterine insemination preparations Semen Analysis ($110) Semen Cryopreservation ($400) Sperm Preparations (for intrauterine insemination) Fresh sample ($100) Frozen sample ($100) Sperm and embryo storage fees ($60/month) Surgeries – male/female TESE/MESA procedures Office hysteroscopy ($1,000) Hyperstim Aspiration LastName, FirstName DOB 7642-xxxxx

Transcript of I. Reproductive Medicine & Infertility Associates (RMIA)...patient is committed to keeping those...

Page 1: I. Reproductive Medicine & Infertility Associates (RMIA)...patient is committed to keeping those dates and will move forward with the IVF procedure. Therefore, for those patients that

© 2016 G:Electronic Documents/181 All Rights Reserved 9/15/16

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Reproductive Medicine & Infertility Associates

In compliance with the Federal Consumer Credit Protection Act, we wish to notify you of our policies regarding the payment of statements for services rendered on your behalf. Please review the following information regarding our two separate corporations, as there are distinct differences between them in the way payment is collected for services rendered. We want to be certain that you are well informed, so that you are able to have your questions answered prior to having any services performed.

I. Reproductive Medicine & Infertility Associates (RMIA)

RMIA/General Reproductive Health Center participates with most major insurance carriers and will provide services including (but not limited to): Physician visits/consults Second opinions Ultrasounds Infertility testing (excluding male diagnostic tests, see below) Ovulation induction Inseminations (excluding sperm preparation, see below) Confirmation of pregnancy General surgery done off-site

RMIA will verify in advance that coverage exist for services regarding consults, general infertility testing, and treatment. If services are covered, then RMIA will bill the insurance carrier directly. Once the insurance carrier has addressed the claim, RMIA will bill the patient for any remaining financial responsibility. If upon verification of insurance benefits it is known that your insurance does not cover certain services rendered by RMIA, then it is our policy to secure a credit card from the patient to cover the services rendered. If a patient hasn’t met his/her financial obligation after a treatment cycle, no further treatment will be conducted until the account has been settled.

II. Infertility Laboratory & Surgery Center Associates (ILSCA) (Prices subject to change)

ILSCA does not participate with any insurance carriers and will provide services including (but not limited to): In vitro fertilization (IVF) Andrology – male diagnostic testing and intrauterine insemination preparations

Semen Analysis ($110) Semen Cryopreservation ($400) Sperm Preparations (for intrauterine insemination)

Fresh sample ($100) Frozen sample ($100)

Sperm and embryo storage fees ($60/month) Surgeries – male/female

TESE/MESA procedures Office hysteroscopy ($1,000) Hyperstim Aspiration

LastName, FirstName DOB 7642-xxxxx

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Payment for all services that fall within the scope of ILSCA is the direct responsibility of the patient, and will be collected in advance. Once services have been provided, then ILSCA will submit a complete HCFA 1500 form to the patient’s insurance carrier on his/her behalf. The insurance carrier will then communicate directly with each patient regarding any possible reimbursement.

Semen Analysis, Semen Cryopreservation: Charges are payable on the day of the specimen

collection. You will need to show the lab staff a receipt that verifies payment prior to collecting the specimen.

Sperm Preparations (for intrauterine insemination): Charges are payable on the day of the insemination prior to the service being performed.

IVF: The full amount of your program fee is collected on the day of your program start. Surgeries: All surgery charges will be collected prior to scheduling the surgical procedure. Sperm cryopreservation is done at the RMIA Woodbury clinic only.

* Please note that we do review benefits with patients but we cannot guarantee actual coverage of

services. One term you may hear from your insurance carrier is “reasonable and customary” or the “allowed amount.” The term reasonable and customary refers to the amount that your health plan determines is the normal range of payment for a specific health related service or medical procedure within a geographical area. If the charges you (or your doctor) submit to your health plan are higher then what the health plan considers normal for the covered service then your health plan may not allow the full amount charged to you.

Helpful tips: Call your insurance carrier and see what your coverage is for both in and out of network Once you have the price your physician charges for a given service, call your insurance

carrier to find out what they will pay off that service. Some insurance carriers provide this type of information on their website, where customers can use what’s called a treatment cost estimator tool

Records Release I hereby authorize Reproductive Medicine and Infertility Associates physicians to release to my referring and/or consulting physician, insurance company, spouse, or legal guardian, any information, diagnosis and records of treatment, concerning my medical history and medical care. Assignment of Benefits I/we hereby authorize that payment of any amount due by insurance be paid directly to: Reproductive Medicine and Infertility Associates. Payment is authorized upon receipt of an itemized statement of services. In consideration of services provided, I am agreeing to pay for services provided to me, to my spouse, and to my minor children. I/we agree to pay all charges not covered by insurance. If I/we fail to make payment upon receipt of monthly billing statement my/our account will be turned over to a collection agency. If a suit is necessary to enforce payment of a delinquent account, patients are liable for “reasonable attorney’s fees” incurred by us. LastName, FirstName

DOB 7642-xxxxx

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Patient Standard of Care Pledge: Physicians and employees at Reproductive Medicine and Infertility Associates (RMIA) and Infertility laboratory & Surgery Center Associates (ILSCA) hereafter referred to as “clinic,” are committed to providing the very best care for our patients. The clinic believes that successful patient outcomes require a compliance partnership between the clinic and the patients. Only with this understanding and commitment, is it possible to insure common expectations. With the following standards in place, both patient and the clinic will be assured of consistent and comprehensive process for patient care and treatment. RMIA, and ILSCA will allocate its resources and expertise to patients, and patients agree, to compliance under the following criteria: Patients’ Agreement to:

Keep scheduled appointments or provide advance notice to RMIA under the cancellation policy.

Follow through with general infertility testing requirements. Comply with referral and authorization requirements. Follow instructions provided by RMIA staff and/or steps outlined in their treatment plan. Meet financial obligations for services rendered at RMIA. Identify their current primary care and Ob/Gyn physicians who can provide non-infertility

services and emergency care. Use after hour telephone service, only for emergency situations as it relates to their care at

RMIA. Provide correct demographic and insurance information. Use RMIA educational tools as identified by RMIA staff (website). Follow RMIA policies provided in your new patient packets. Make suggestions for improvement so that RMIA can improve patient satisfaction. Treat all RMIA employees with respect. Follow RMIA’s NO cell phone policy.

Clinic’s Agreement to:

Professional and supportive care and treatment directed by RMIA Physicians. Credentialed physicians and nurses with the American Society of Reproductive Medicine. Embryology, Andrology, and Endocrine inspected and certified laboratories. State of the art facilities, equipment, and standards of medical services. Provide prompt and courteous service to all of our patients. Multiple options of treatment plans to meet patient needs. Cooperative arrangements with local physicians (in-state and out-of-state) where

appropriate to quality care continuity. Protection and confidentiality of health information under HIPAA Guidelines. Member in good standing with national SART, national organization for fertility patient

reporting. Be treated with respect from all RMIA employees.

LastName, FirstName DOB 7642-xxxxx

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We appreciate the time and financial considerations that are part of our commitment as partners in your care for infertility treatment and we establish these guidelines to care because our experience has shown they increase the opportunity for successful outcomes. We thank you for your understanding and compliance. As in all medical care, the physician may determine transferring care to another provider if it’s in the best interest of the patient.

*YOU WILL SIGN THIS FORM AT CHECK-IN*

LastName, FirstName DOB 7642-xxxxx

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© 2019 G:ElectronicDocuments/1648 All Rights Reserved 1/15/19

Addendum Cancellation and/or Rescheduling Clause

After your program start, an IVF scheduling nurse will discuss possible dates for your cycle monitoring and IVF procedure. The IVF scheduling nurse will schedule dates as promptly as the physician schedule permits. You have the right to accept or decline these dates. However, if declined, RMIA expects a call back in a timely manner with other potential dates. Please note that when we schedule an IVF procedure, we are dedicating a spot and committing time and resources on that particular week for your procedure. There is a limited amount of time slots available each week, and once full, the IVF scheduling nurse will need to look at the physicians schedule to see when the next opening is, probably not until the following month. RMIA is committed to scheduling your IVF dates timely, and expects once the dates are agreed upon, the patient is committed to keeping those dates and will move forward with the IVF procedure. Therefore, for those patients that cancel and/or rescheduled their IVF dates, certain monetary penalties will be charged based on the length of time before cancellation. These charges will need to be paid in full, before any further IVF scheduling. Charges up to the point of cancellation will be assessed on a fee for service basis regardless of the patients IVF program.

$200 fee will be assessed to patients who cancel or reschedule > 6 weeks prior to their scheduled TVOR or Frozen Embryo Transfer.

$500 fee will be assessed to patients who cancel or reschedule < 6 weeks prior to their scheduled

TVOR or Frozen Embryo Transfer.

$1,000 fee will be assessed to patients who cancel or reschedule < 2 weeks prior to their scheduled TVOR or Frozen Embryo Transfer.

$2,000 fee will be assessed to patients who cancel or reschedule once their HCG medication has

been administered and/or who fail to take their HCG.

Changes in embryo transfer plan made at the last minute are strongly advised against, as they have the potential to lead to additional procedures and/or rescheduling (charges will be applied). In some cases, such changes may lead to disqualification from the current program.

We acknowledge by our signature below that we have read the above and have had all our questions answered to our complete satisfaction. We also agree that RMIA may charge our credit card on file for any cancellation fee that may be incurred. Date: ______________ ________________________________________________ Patient Name (print) ________________________________________________ Patient Signature Date: ______________ ________________________________________________ Partner Name (print) ________________________________________________ Partner Signature LastName, FirstName

DOB 7642-xxxxx

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RMIA MD:_______ © 2019 G:Electronic Documents/41 All Rights Reserved 7/11/19

Reproductive Medicine & Infertility Associates PHYSICIAN IDENTIFICATION FORM

Reproductive Medicine and Infertility Associates (RMIA) specializes exclusively in the evaluation and treatment of infertility. During the course of your care with us, medical situations may arise which require expertise and facilities more readily available through the office of an obstetrician/gynecologist. Before beginning treatment at RMIA, please designate, and update as necessary, the information requested below. Current demographic information helps assure that your care remains timely and that your insurance benefits and authorizations are current. Primary physician: A physician (usually a family practitioner or internist) you see for general health care; i.e. sore throats, physical examinations, etc. On occasion, a family practice physician may provide uncomplicated or routine obstetrical and gynecological care. OB/GYN physician: A physician who specializes in women’s health care- specifically gynecology, pregnancy and their attendant complications. Referring physician: A referral is a formal authorization to see a specialist or subspecialist which may be required by your insurance company. Your referring physician is usually the person designated by you as your primary physician. Depending upon the restrictions of your individual policy, an OB/GYN physician can also be your referring physician. More commonly, your OB/GYN will recommend you visit with us, but can only generate a formal referral to RMIA if he/she has been designated by you as your primary physician.

PRIMARY CLINIC PRIMARY PHYSICIAN (first & last name) PRIMARY PHYSICIAN ADDRESS PRIMARY PHYSICIAN PHONE # PRIMARY PHYSICIAN FAX #

OB/GYN CLINIC OB/GYN PHYSICIAN (first & last name) OB/GYN CLINIC ADDRESS OB/GYN PHYSICIAN PHONE # OB/GYN PHYSICIAN FAX #

REFERRING PHYSICIAN (first & last name) (IF DIFFERENT THAN ABOVE) REFERRING PHYSICIAN ADDRESS REFERRING PHYSICIAN PHONE # REFERRING PHYSICIAN FAX # Printed Name Signature Date

LastName, FirstName DOB 7642-xxxxx

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© 2018 G:Electronic Documents/1988 All Rights Reserved 11/13/18

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Protected Health Information (PHI) may include information/documents regarding medical treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test results; account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third party financing.

HIPAA regulations authorize the release of PHI for the purpose of treatment, obtaining payment from third party payers, and the day-to-day healthcare operations of Reproductive Medicine &Infertility Associates (RMIA). Other than those releases authorized by HIPAA, PHI will only be released to persons listed on this Authorization below.

This Authorization is voluntary and only applies to protected health information related to medical care received by RMIA. Treatment or payment for services are not conditioned on signing the authorization.

I understand that the information that is used or disclosed in accordance with this Authorization may be subject to re-disclosure by the Recipient(s) listed below and, in that case, will no longer be protected by HIPAA.

I understand that I may revoke this authorization at any time prior to its expiration date by providing written notification to Ada Dow, Privacy Officer, Reproductive Medicine &Infertility Associates, 2101 Woodwinds Drive, Suite 100, Woodbury, MN 55125, but the revocation will not have any effect on any actions taken in reliance of this authorization or relating to the use or disclosure of the protected health information that RMIA took before it received the revocation.

This Authorization shall remain in effect until either: (a) its expiration date of 1 year, on _______________________ or (b) RMIA receives a written revocation of the authorization. ACCEPTANCE

I, _________________________________________, hereby authorize the use or disclosure of my protected health information to the following person(s):

NAME OF PERSON #1

NAME OF PERSON #2

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

DECLINATION

I, _________________________________________, hereby decline authorization to use or disclose my protected health information to anyone. (Patient must also sign “HIPAA Request for Limitations & Restrictions of PHI” ED-597)

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

I authorize continuation of this release (authorization will be valid for another year): PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642- LastName, FirstName DOB 7642-xxxxx

christine
Typewritten Text
TO BE SIGNED BY PATIENT
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© 2018 G:Electronic Documents/1988 All Rights Reserved 11/13/18

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Protected Health Information (PHI) may include information/documents regarding medical treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test results; account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third party financing.

HIPAA regulations authorize the release of PHI for the purpose of treatment, obtaining payment from third party payers, and the day-to-day healthcare operations of Reproductive Medicine &Infertility Associates (RMIA). Other than those releases authorized by HIPAA, PHI will only be released to persons listed on this Authorization below.

This Authorization is voluntary and only applies to protected health information related to medical care received by RMIA. Treatment or payment for services are not conditioned on signing the authorization.

I understand that the information that is used or disclosed in accordance with this Authorization may be subject to re-disclosure by the Recipient(s) listed below and, in that case, will no longer be protected by HIPAA.

I understand that I may revoke this authorization at any time prior to its expiration date by providing written notification to Ada Dow, Privacy Officer, Reproductive Medicine &Infertility Associates, 2101 Woodwinds Drive, Suite 100, Woodbury, MN 55125, but the revocation will not have any effect on any actions taken in reliance of this authorization or relating to the use or disclosure of the protected health information that RMIA took before it received the revocation.

This Authorization shall remain in effect until either: (a) its expiration date of 1 year, on _______________________ or (b) RMIA receives a written revocation of the authorization. ACCEPTANCE

I, _________________________________________, hereby authorize the use or disclosure of my protected health information to the following person(s):

NAME OF PERSON #1

NAME OF PERSON #2

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

DECLINATION

I, _________________________________________, hereby decline authorization to use or disclose my protected health information to anyone. (Patient must also sign “HIPAA Request for Limitations & Restrictions of PHI” ED-597)

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

I authorize continuation of this release (authorization will be valid for another year): PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642-

PATIENT SIGNATURE____________________________________ DATE___________________ ID 7642- LastName, FirstName DOB 7642-xxxxx

christine
Typewritten Text
TO BE SIGNED BY PARTNER, IF APPLICABLE
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© 2019 G:Electronic Documents/1752 All Rights Reserved 6/18/19

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EMAIL CONSENT FORM

EMERGENCY PROBLEMS E-mail should never be used for emergency situations. In the event of an emergency, call 911 URGENT PROBLEMS E-mail should never be used for urgent situations. In these cases, the patient should call our main number 651-222-6050 during business hours (M-F 7:30-4:30). After hours you can contact our on call answering service or go to an urgent care. 1. RISKS OF USING E-MAIL TO COMMUNICATE WITH YOUR CLINIC

Reproductive Medicine & Infertility Associates referred throughout this consent as “Clinic.”

The Clinic offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patient should consider before using e-mail to communicate with the Clinic. These include, but not limited to, the following risks:

E-mail can be circulated, forwarded, and stored in numerous paper and electronic files E-mail sender can type in the wrong email address Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy. Employers have a right to archive and inspect e-mails transmitted through their system. E-mails can be used to introduce viruses into computer systems E-mail can be intercepted, altered, forwarded, or used without authorization or detection. E-mails can be used as evidence in court.

2. CONDITIONS FOR THE USE OF E-MAIL

Provider will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, the Clinic cannot guarantee the security and confidentiality of e-mail communication and will not be liable for improper disclosure and confidential information that is not caused by the Clinics intentional misconduct. Thus, patient must consents to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions:

a) All e-mails concerning diagnosis or treatment will become part of the patients medical records. b) Patient shall not use e-mails for medical emergencies, urgent problems or other sensitive matters. c) If the patient has not received a response back from the Clinic within a reasonable time period, it

is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond.

d) The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding, but not limited to laboratory testing, mental health, or health history.

e) The patient is responsible for protecting his/her password or other means of access to e-mail. The Clinic is not liable for breaches of confidentiality caused by the patient or any third party.

f) Clinic shall not engage in e-mail communication that is unlawful. g) It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.

3. PATIENT RESPONSIBILITIES AND INSTRUCTIONS

To communicate by e-mail, the patient shall: a) Limit or avoid use of his/her employer’s computer b) Inform Clinic of changes in his/her e-mail c) Put the patient’s name in the body of the e-mail. d) Include the category of the communication in the e-mail’s subject line LastName, FirstName

DOB 7642-xxxxx

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e) Review the e-mail to make sure it is clear and that all relevant information is provided before sending the e-mail.

f) Take precautions to preserve the confidentiality of the e-mail, such as using screen savers and safeguarding his/her computer password.

4. ALTERNATE FORMS OF COMMUNICATION

I understand that I may also communicate with the Clinic via telephone or during a scheduled appointment and that e-mail is not a substitute for the care that may be provided during an office visit. Appointment should be made to discuss any new issues as well as sensitive medical information. I also understand that the Clinic also utilizes Notify MD as I go through active treatment and that is also a way to communicate results and changes in my treatment plan.

5. TYPES OF E-MAIL TRANMISSIONS THAT PATIENT AGREES TO SEND AND/OR RECEIVE The types of information that can be communicated by e-mail with the Clinic include prescription refills, patient referrals and appointment scheduling reminders and requests, billing and insurance questions, consultation summaries, signed consent forms, IVF treatment plan (calendar) and instructions, and patient education. If you are not sure if the issue you wish to discuss should be included in an e-mail, you should call the Clinic to schedule an appointment. If you elect not to provide us with your email, but contact us through e-mail, we will correspond to any email sent to us. In most occasions, you will receive an encrypted email via ZixMail. You must provide a username and password to log into ZixMail to retrieve your message(s). The Clinic will be notified of any message not picked up. The Clinic will make one attempt to resend via ZixMail or will mail document(s) to you. If you do not receive our email(s), please check your spam or junk mail folder. If you find it there, please identify it as “non-junk” or “non-spam” email. You may also want to add [email protected] to your contact or ‘Safe Sender’ list so that these emails do not go to your junk mail folder.

6. SECURITY MEASURES USED BY CLINIC As stated above, communication via e-mail does come with privacy risks as stated above. While the Clinic can not guarantee total confidentiality, the Clinic will use reasonable safeguards to protect your health information as required by law.

7. HOLD HARMLESS

I agree to hold harmless the Providers, Reproductive Medicine & Infertility Associates, its employees, and website designers against all losses, expenses, damages, costs, including attorney’s fees, relating to information loss due to technical failure. The Clinic does not warrant that the functions contained in any material provided will be uninterrupted or error-free, that defects will be corrected, or that the Clinic website or server that makes such site available is free of viruses or other harmful components.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT I have discussed with the Clinic representative and we acknowledge that I have read and fully understand the consent form. We understand the risks associated with the communication of e-mail between the Clinic and us, and consent to the conditions herein.

*YOU WILL SIGN THIS FORM AT CHECK-IN*

LastName, FirstName DOB 7642-xxxxx

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Reproductive Medicine and Infertility Associates

IVF Program Criteria

Criteria

FCWP < 39 (with or without

PGD/S)

FCWP < 35 (100%) or HOPE

(with or without PGD/S)

FCWP using GC (with or without

PGD/S)Reg IVF with

own eggsReg IVF with GC

Reg IVF with PGD/S

Reg IVF with donor egg FET

Egg Freezing

Age < 39 < 35 < 39 < 43 < 51 < 40 < 51 < 51 < 40(Single patients >55 or couples with a combined age of >110 will be excluded. Single patients >50 and couples with a combined age of >100 will be considered on a case by case basis)

(Treatment anticipated to start within 30 days of

consent signing)

(Treatment anticipated to start within 30 days of

consent signing)

(if using own eggs) (40-42 considered on a case by case

basis. Patients >35 may require 1-2

additional cycles of embryo banking)

(45-50 requires clearance from a

perinatologist before doing any

prescreening at RMIA)

BMI (calculate your BMI) ≤ 35.0 > 19 and < 33.0 ≤ 35.0 ≤ 35.0 ≤ 35.0 ≤ 35.0 ≤ 37.0 ≤ 37.0 ≤ 35.0

FSH ≤ 10 ≤ 10 ≤ 10 ≤ 12 ≤ 12 ≤ 12 N/A N/A N/A

AMH AMH ≥ 1, or normal ovarian response

AMH ≥ 1.5, or normal ovarian response

AMH ≥ 1, or normal ovarian response ≥ 0.5 ≥ 0.5 ≥ 0.5 N/A N/A N/A

(or AFC) (or AFC) (or AFC)

Motile Sperm ≥ 100,000 ≥ 100,000 ≥ 100,000 any live sperm any live sperm any live sperm N/A N/A N/A

Uterine cavity normal normal normal normal normal normal normal normal N/A

Previous unsuccessful IVF cycles

requires approval from RMIA physician none requires approval from

RMIA physician N/A N/A N/A N/A N/A N/A

Miscarriages

> 2 miscarriages requires approval from RMIA physician. Additional

testing may be needed.

> 2 miscarriages requires approval from RMIA physician. Additional

testing may be needed.

> 2 miscarriages requires approval from RMIA physician. Additional

testing may be needed.

N/A N/A N/A N/A N/A N/A

Corrective surgery for: Distal tubal occlusion Yes Yes N/A Yes N/A Yes Yes Yes N/A Tubal disease associated with ≥ 1 tubal pregnancy 2 tubal pregnancies, irrespective of tubal status

Conditions that will predictably decrease success rate: Smoking * No No No No No No No No No High risk for poor No No No N/A N/A N/A N/A N/A N/A obstetrical outcome Some medications No No No N/A N/A N/A N/A N/A N/A Chromosome anomalies No No No N/A N/A N/A N/A N/A N/A and/or PGD need

*ALL patients (female and male) must quit all tobacco use (cigarette, cigar, pipe) and vaping one month prior to consent signing. Nicorette gum is permitted.

≥ 100,000

FCWP Donor Egg (with or without

PGD/S)

< 51(45-50 requires

clearance from a perinatologist before

doing any prescreening at RMIA)

≤ 37.0

N/A

N/A

normal and normal response to HRT

N/A

N/A

Yes

No

NoNo

No

G:ElectonicDocuments/1241 11/7/19

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LastName, FirstName DOB 7642-xxxxx

Page 13: I. Reproductive Medicine & Infertility Associates (RMIA)...patient is committed to keeping those dates and will move forward with the IVF procedure. Therefore, for those patients that

G:Electronic Documents/208 10/7/16

RMIA Woodbury 2101 Woodwinds Drive,

Suite 100 Woodbury, MN 55125

651-222-6050

Directions from Minneapolis and/or St. Paul

I-94 East to I-494 South I-494 South to Lake Road (approximately 2-1/2 miles) Cross Lake Road onto Woodwinds Drive (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive

Directions from the South

I-35E North to I-494 East I-494 to Lake Road (approximately 10 miles) exit Lake Road, turn left (west) Lake Road (cross I-494) to Woodwinds Drive, turn right (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive

Directions from the North

I-35E South to I-694 East I-694 will change to I-494 south as it crosses I-94 I-694/I-494 to Lake Road (approximately 8 miles) exit Lake Road Cross Lake Road onto Woodwinds Drive (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive

Directions from the East

I-94 W to I-494 South I-494 South to Lake Road exit Lake Road Cross Lake Road onto Woodwinds Drive (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive

LastName, FirstName DOB 7642-xxxxx

Page 14: I. Reproductive Medicine & Infertility Associates (RMIA)...patient is committed to keeping those dates and will move forward with the IVF procedure. Therefore, for those patients that

G:Electronic Documents/208 10/7/16

RMIA Edina 3625 West 65th Street

Suite 200 Edina, MN 55435

651-222-6050

Directions from St. Paul

I-35W S to MN-62 W MN-62 W to France Ave. S. Turn left onto France Ave S. Turn left onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts)

Directions from the West

MN-62 E to France Ave. S. Turn right onto France Ave S. Turn left onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts)

Directions from the North

MN-100 S to MN-62 E MN-62 E to France Ave. S. Turn right onto France Ave S. Turn left onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts)

Directions from the South

I-35W N to I-494 W I-494 W to France Ave. S. Turn right onto France Ave S. Turn right onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts)

LastName, FirstName DOB 7642-xxxxx